Intensive Care Med DOI 10.1007/s00134-015-3749-6
Wei-Ting Chang Nan-Haw Chow Yi-Shan Tsai Chih-Chan Lin
IMAGING IN INTENSIVE CARE MEDICINE
Acute ruptured mycotic aneurysm mimicking myocardial tumor with ST elevation myocardial infarction
Received: 8 March 2015 Accepted: 10 March 2015 Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 Electronic supplementary material The online version of this article (doi:10.1007/s00134-015-3749-6) contains supplementary material, which is available to authorized users. W.-T. Chang C.-C. Lin Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan N.-H. Chow Department of Pathology, National Cheng Kung University College and Hospital, Tainan, Taiwan Y.-S. Tsai Department of Radiology, National Cheng Kung University College and Hospital, Tainan, Taiwan C.-C. Lin ()) Division of Cardiology, Department of Internal Medicine, National Cheng Kung University College and Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan e-mail: [email protected] Tel.: ?886-6-235-3535
A 50-year-old woman presented with chest tightness and shock. She had a history of hypertension and diabetes, and she had just been discharged for Staphylococcus aureus
infection. Electrocardiography showed complete atrioventricular block and ST elevation over inferior leads giving the impression of myocardial infarction. Coronary angiography was therefore performed and demonstrated one huge coronary aneurysm at the proximal left anterior descending artery (LAD) (Fig. 1a). Also, the totally occluded right coronary artery (RCA) indicated the infarctrelated artery (Supplementary Fig. 1a). Owing to failed attempts to open the RCA, computed tomography was utilized to delineate the structures before bypass surgery. Surprisingly, in addition to the LAD pseudoaneurysm (Fig. 1b) a focal mass-like lesion encased the proximal RCA (Supplementary Fig. 1b). Fever and profound shock raged but emergent surgery could not prevent the patient’s death. Postmortem blood culture yielded S. aureus. Autopsy revealed the ruptured pseudoaneurysm in the LAD and subsequent hematoma, which caused myocardial necrosis of the anterior wall (Fig. 1c). Similarly, hematoma along the right atrium, supposedly from the ruptured pseudoaneurysm, also compromised the RCA (Supplementary Fig. 1c). The disruptive single layer pseudoaneurysm and dissection flap were observed microscopically. Atherosclerosis and thrombosis inside the LAD and RCA contributed to the occlusion (Fig. 1d, Supplementary Fig. 1d). Coronary artery mycotic aneurysm is a rare cause of myocardial infarction. The consequent hematoma caused by a ruptured aneurysm may imitate a cardiac tumor. As in the current case, imaging investigations are useful; however, only prompt surgery and histologic proof indicate a definite diagnosis and better outcome.
Fig. 1 Left coronary angiography demonstrated a one huge coronary aneurysm at the proximal LAD with delayed distal flow running off and CT further delineating b the ruptured pseudoaneurysm at the LAD, surrounded by hematoma (large arrows).
Autopsy indicated c the ruptured aneurysm and subsequent hematoma at the LAD (small arrows), compatible with the histology findings (9100), d atherosclerosis and a single layer pseudoaneurysm (asterisk) at the LAD
Wei-Ting Chang Nan-Haw Chow Yi-Shan Tsai Chih-Chan Lin
IMAGING IN INTENSIVE CARE MEDICINE
Acute ruptured mycotic aneurysm mimicking myocardial tumor with ST elevation myocardial infarction
Received: 8 March 2015 Accepted: 10 March 2015 Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 Electronic supplementary material The online version of this article (doi:10.1007/s00134-015-3749-6) contains supplementary material, which is available to authorized users. W.-T. Chang C.-C. Lin Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan N.-H. Chow Department of Pathology, National Cheng Kung University College and Hospital, Tainan, Taiwan Y.-S. Tsai Department of Radiology, National Cheng Kung University College and Hospital, Tainan, Taiwan C.-C. Lin ()) Division of Cardiology, Department of Internal Medicine, National Cheng Kung University College and Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan e-mail: [email protected] Tel.: ?886-6-235-3535
A 50-year-old woman presented with chest tightness and shock. She had a history of hypertension and diabetes, and she had just been discharged for Staphylococcus aureus
infection. Electrocardiography showed complete atrioventricular block and ST elevation over inferior leads giving the impression of myocardial infarction. Coronary angiography was therefore performed and demonstrated one huge coronary aneurysm at the proximal left anterior descending artery (LAD) (Fig. 1a). Also, the totally occluded right coronary artery (RCA) indicated the infarctrelated artery (Supplementary Fig. 1a). Owing to failed attempts to open the RCA, computed tomography was utilized to delineate the structures before bypass surgery. Surprisingly, in addition to the LAD pseudoaneurysm (Fig. 1b) a focal mass-like lesion encased the proximal RCA (Supplementary Fig. 1b). Fever and profound shock raged but emergent surgery could not prevent the patient’s death. Postmortem blood culture yielded S. aureus. Autopsy revealed the ruptured pseudoaneurysm in the LAD and subsequent hematoma, which caused myocardial necrosis of the anterior wall (Fig. 1c). Similarly, hematoma along the right atrium, supposedly from the ruptured pseudoaneurysm, also compromised the RCA (Supplementary Fig. 1c). The disruptive single layer pseudoaneurysm and dissection flap were observed microscopically. Atherosclerosis and thrombosis inside the LAD and RCA contributed to the occlusion (Fig. 1d, Supplementary Fig. 1d). Coronary artery mycotic aneurysm is a rare cause of myocardial infarction. The consequent hematoma caused by a ruptured aneurysm may imitate a cardiac tumor. As in the current case, imaging investigations are useful; however, only prompt surgery and histologic proof indicate a definite diagnosis and better outcome.
Fig. 1 Left coronary angiography demonstrated a one huge coronary aneurysm at the proximal LAD with delayed distal flow running off and CT further delineating b the ruptured pseudoaneurysm at the LAD, surrounded by hematoma (large arrows).
Autopsy indicated c the ruptured aneurysm and subsequent hematoma at the LAD (small arrows), compatible with the histology findings (9100), d atherosclerosis and a single layer pseudoaneurysm (asterisk) at the LAD
